2017 Opioid Prescribing & Treatment Guidelines - COLORADO ACEP - Confronting the Opioid Epidemic in Colorado's Emergency Departments
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COLORADO ACEP 2017 Opioid Prescribing & Treatment Guidelines Confronting the Opioid Epidemic in Colorado’s Emergency Departments
DISCLAIMER AND COPYRIGHT NOTICE
The Colorado Chapter of the American College of Emergency Physicians (COACEP) makes every effort to ensure that contributors to
its publications are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed
in this publication are provided as the contributors’ recommendations at the time of publication and should not be construed as official
College policy. ACEP recognizes the complexity of emergency medicine and makes no representation that this publication serves as
an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis
for the definition of, or standard of care that should be practiced by all health care providers at any particular time or place. Drugs
are generally referred to by generic names. In some instances, brand names are added for easier recognition. COACEP received no
commercial support for this publication. To the fullest extent permitted by law, and without limitation, COACEP expressly disclaims
all liability for errors or omissions contained within this publication, and for damages of any kind or nature, arising out of use,
reference to, reliance on, or performance of such information.
Copyright 2017, COACEP. All rights reserved. Except as permitted under the US Copyright Act of 1976, no part of this publication
may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including storage and retrieval
systems, without permission in writing from the publisher.
COLORADO CHAPTER, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS
10465 Melody Dr. #101, Northglenn, CO 80234
Phone: 303.255.2715
Fax: 303.255.2704
Barbara Burgess, Executive Director
bburgess@estreet.com
ii
Dedicated to the men and women
who staff emergency departments across
Colorado — 24 hours a day, 7 days a week —
and the patients for whom they care.
EDITOR-IN-CHIEF
Donald E. Stader III, MD, FACEP
dstader@carepointhc.com
ASSOCIATE EDITORS
Rachael Duncan, PharmD & Erik Verzemnieks, MD
SECTION EDITORS
Stephen V. Cantrill, MD, FACEP The Opioid Epidemic in Colorado
Christopher Johnston, MD, FACEP Limiting Opioid Use in the ED
Rachael Duncan, PharmD Alternatives for the Treatment of Pain
Jason Hoppe, DO, FACEP & Donald E. Stader III, MD, FACEP Harm Reduction in the ED
Kevin Kaucher, PharmD Treatment of Opioid Addiction
PUBLICATION EDITOR
Rachel Donihoo
TASK FORCE MEMBERS & VOLUNTEERS
Travis Barlock
Kerry Broderick, MD
Colleen Decker, RN
Jasmeet Dhaliwal, MD
Hannah Gunther
Stefanie Huff, MD
Nathan Hibbs, MD, FACEP
Kevin McGarvey, MD, FACEP
Daniel Morrad
Dawn O’Keefe, RN
Eric Olsen, MD, FACEP
Madeleine Ponder, MD
Lisa Raville, Executive Director, Harm Reduction Action Center
Jack Spartz
Debra Starin, Addiction Counselor
Gannon Sungar, MD
Robert Valuck, PharmD, Executive Director, Colorado Consortium
Anne Winiarski, MD
Table of Contents
I. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
II. The Opioid Epidemic in Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
III. Limiting Opioid Use in the ED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
IV. Alternatives to Opioids for the Treatment of Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
V. Harm Reduction in the Emergency Department. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
VI. Treatment of Opioid Addiction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
VII. The Future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Appendix 1. ALTO Protocols and References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Appendix 2. ALTO Prescribing Guide for Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Appendix 3. Suboxone for Withdrawal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
iv
I. Introduction
As physicians, we are on the front lines of an opioid epidemic that is crippling communities across
the country. We must accept and embrace our professional responsibility to treat our patients’ pain
without worsening the current crisis. These are actions we must take as physicians individually and
collectively to do our part to end this epidemic.1
Stephen Stack, MD, AMA President & Emergency Physician (2016)
Emergency providers across Colorado and our nation are facing one of the greatest public health crises of our
generation. Opioids, both prescription and illicit, have become the leading cause of accidental death in the United States.
Correspondingly, hospital visits for opioid overdose, drug-related complications, and “doctor shopping” have become an
increasingly common part of emergency medicine practice. The number of lives impacted by this epidemic is astonishing.
The Centers for Disease Control and Prevention (CDC) reports that opioid overdose killed nearly half a million Americans
between 2000 and 2014, and another 78 are dying every day. What makes this crisis especially tragic is that organized
medicine and the practice patterns of physicians have played a prominent role in creating it.
The pharmaceutical use of opioids skyrocketed between 1990 and 1996; prescriptions for fentanyl rose 1,000%, followed by
morphine (49%), oxycodone (15%), and hydromorphone (12%).2 Our appetite for these drugs has become insatiable. The
number of prescription opioids sold in the US has quadrupled since 1999, with Americans consuming nearly 100% of the
global supply of hydrocodone and 81% of oxycodone.3,4 Despite a growing awareness about the addictive and potentially
deadly effects of these drugs, their popularity thrives (Figure 1).
The number of emergency department (ED) visits precipitated by the nonmedical use of opioids has grown 183% since
2011.5 From 2003 to 2013 treatment admissions for non-heroin opioid abuse escalated from 3% to 9%.6 In the same decade,
the prevalence of positive opioid tests tripled among drivers who died within one hour of a motor vehicle accident.7 The
financial implications of this epidemic are equally staggering; the nonmedical use of opioid pain relievers costs insurance
companies an estimated $78.5 billion annually.8
FIGURE 1. PAINKILLERS IN AMERICA
Number of painkiller
prescriptions
per 100 people
52–71
72–82.1
82.2–95
96–143
Source: IMS, National Prescription Audit (NPA ), 2012.
1While a number of external factors have contributed to the liberal use of these potentially lethal drugs, the medical
community is compelled to acknowledge its central role in creating our national addiction. However, we also have the
power to reverse these grim statistics by reforming our practices with resolve and innovation.
Colorado ACEP is proud to present its Colorado Emergency Department Opioid Prescribing and Treatment Guidelines.
Among the most comprehensive ever published, these recommendations were developed by a panel of more than 20
experts, including emergency physicians, addiction and harm reduction specialists, pharmacists, paramedics, emergency
department nurses, and medical students.
These guidelines are not meant to replace clinical judgment, but rather inform and augment it. Although we acknowledge
the value of opioids in certain clinical situations, including the treatment of cancer pain or hospice patients, we advocate
extreme caution in all cases. Emergency clinicians must recognize that chronic opioid use and abuse often starts with
acute pain. Although many dismiss the risks of short-term opioid prescriptions, roughly 16% of patients who receive more
than a 1-week supply report a reliance on these drugs 1 year later. Only 6% of patients who receive a single-day supply
report continued use.9 Here we provide an approach to pain management aimed at decreasing the morbidity and mortality
associated with opioid use and abuse.
2II. The Opioid Epidemic in Colorado
The US has seen a fourfold spike in the number of opioid prescriptions written since 1999; Colorado alone has seen a 100%
increase (7.9:100,000 vs 15.8:100,000).10 The statistics for opioid-related poisoning deaths are equally disturbing (Figure 2).
The age-adjusted death rate for non-heroin opioid overdose in Colorado rose from 2.0 per 100,000 in 2000 to 6.1 in 2014
(205% increase), while heroin-related deaths increased from 0.8 to 2.8 per 100,000 (250% increase).10
Colorado Statistics
• From 2012 to 2013, Colorado ranked 12th nationally in the self-reported nonmedical use of opioids.11
• 25% of Coloradans admit to using pain medications in non-prescribed ways.12
• 29% of Coloradans have used pain medications belonging to others.12
• The number of heroin-related felony arrests increased 170% between 2011 and 2015.13
• The number of prescription drug arrests increased 27% between 2011 and 2015.13
• The amount of heroin seized annually has increased 827% since 2011.13
• Nearly 20,000 dosage units of prescription drugs have been seized annually between 2011 and 2015; however, this
number appears to be decreasing.13
FIGURE 2. OPIOID-RELATED DEATH IN COLORADO
Colorado Drug Overdose Death Rate, 2014 Colorado Drug Overdose Death Rate, 2002
Sedgwick
Sedgwick
Moffat Weld Logan
Larimer Moffat Weld Logan
Jackson Phillips Larimer
Jackson Phillips
Routt
Routt
Morgan
Morgan
Grand Boulder
Rio Blanco Grand Boulder
Denver Yuma Rio Blanco
Gilpin Denver Yuma
Adams Washington Gilpin Adams
Jefferson
Washington
Jefferson
Clear Creek Arapahoe
Eagle Clear Creek Arapahoe
Summit Eagle
Summit
Elbert Kit Carson
Pitkin Elbert Kit Carson
Mesa Douglas Pitkin
Lake Park Mesa Douglas
Lake Park
Teller
Delta El Paso Cheyenne Teller
Delta El Paso Cheyenne
Chaffee Lincoln
Chaffee Lincoln
Gunnison
Gunnison
Montrose Fremont Kiowa
Montrose Fremont Kiowa
Crowley
Crowley
Ouray Custer Pueblo
San Miguel Saguache Ouray Custer Pueblo
Hinsdale Prowers San Miguel Saguache
Bent Hinsdale Prowers
Otero Bent
Dolores Otero
San Juan Mineral Huerfano Dolores
San Juan Mineral Huerfano
Rio Grande Alamosa
Rio Grande Alamosa
Montezuma
Montezuma
La Plata Las Animas Baca
Conejos Costilla La Plata Las Animas Baca
Archuleta Conejos Costilla
Archuleta
Legend
Legend
1 2 3 4 5 6 7 8 9 10 11 No Data Available
1 2 3 4 5 6 7 8 9 10 11 No Data Available
0–2.0 2.1–4.0 4.1–6.0 6.1–8.0 8.1–10.0 10.1–12.0 12.1–14.0 14.1–16.0 16.1–18.0 18.1–20.0 >20.0
0–2.0 2.1–4.0 4.1–6.0 6.1–8.0 8.1–10.0 10.1–12.0 12.1–14.0 14.1–16.0 16.1–18.0 18.1–20.0 >20.0
How Did We Get Here?
In 1986 prominent pain expert Russell Portenoy published a limited case series of 38 patients, which suggested that chronic
noncancer pain could be managed safely with high doses of opioids without posing a risk of addiction.14 His proposal was
embraced by those involved in the care of chronic pain patients and endorsed by both the American Academy of Pain
Medicine and the American Pain Society.15 Subsequently, many pharmaceutical companies began to aggressively market
their opioids for wider use at increased dosages. This movement — whether intentional or not — was encouraged by the
Joint Commission, which in 2001 named pain the “fifth vital sign.”16,17
The growing emphasis on pain control was further encouraged by the Institute of Medicine in its seminal report, Relieving
Pain in America, which stated that “effective pain management is a moral imperative, a professional responsibility, and
the duty of people in the healing professions.” The report also stated that “relieving pain should be a national priority.”18
Additional pressures have been brought to bear on clinicians by the increasing prevalence of patient satisfaction surveys,
which often stress timely and “adequate” pain control. These surveys frequently are tied to clinician remuneration. 19,20
3Of note, the scientific validity of Portenoy’s original work has been called into question; in recent years, the researcher
himself has publicly doubted the relative efficacy and safety of long-term opioid use for the treatment of chronic noncancer
pain.21-24
WHAT’S OUR ROLE?
Emergency physicians write 12% of the opioids taken by patients between the ages of 10 and 29 years, putting our
specialty third in the number of prescriptions written, behind family physicians and dentists.25 Clinicians must rely on
their own discretion when treating pain, while striking a balance between oligoanalgesia (ie, inadequate pain control) and
the unnecessary use of opioids. Likewise, pain management in the prehospital setting also presents a dilemma for EMS
professionals, who are compelled to provide adequate relief while remaining cognizant of the potential for opioid misuse
and abuse.26
Despite a prevalent fear that failing to give patients “what they want” might violate the Emergency Medical Treatment &
Labor Act (EMTALA), this concern is unfounded. Pain is not considered an “emergency medical condition,” and discharg-
ing patients without relieving their reported discomfort does not violate this mandate.27
There soon may be additional consequences to the prescribing of opioids. In 2015 the West Virginia Supreme Court ruled
that patients who become addicted to prescription medications may sue care providers and pharmacies for addiction-
related damages.28 Although the short- and long-term impact of this ruling on emergency medicine remains unclear, it is
another important reason to make judicious decisions when administering potentially harmful drugs.
4III. Limiting Opioid Use in the ED
“An ounce of prevention is worth a pound of cure.”
—Benjamin Franklin
The vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from
a doctor. For many years medical providers were taught that oligoanalgesia was morally reprehensible — a rampant
problem that could be solved by narcotics. This marketing campaign was further fueled by the rising popularity of patient
satisfaction surveys and similar ideologies, US opioid sales from 1999 to 2014 rose by nearly 400%.29 Once reserved for
only the most severe pain, these agents quickly became routine even for the treatment of minor discomfort.
Heroin use has increased an estimated 37% per year since 2010; 4 in 5 new heroin users start by misusing prescription
opioids (Figure 3).30 Many patients who begin with prescription opioid abuse eventually transition to intravenous (IV) use
or IV heroin abuse when they can no longer acquire or afford prescription drugs, or when tolerance dictates injection to
achieve the same “high” or prevent withdrawal symptoms.
The first step in reversing these alarming trends is to decrease the frequency and ease with which opioids are dispensed.
Emergency clinicians must be vigilant when screening patients, prescribe narcotics conservatively, and provide thorough
counsel on the risks of dependency prior to discharge.
FIGURE 3. HEROIN USE AS PART OF A LARGER ABUSE PROBLEM
Nearly every patient who
uses heroin also uses at People who are addicted to...
least one other drug.
Most use at least
3 other drugs.
ALCOHOL MARIJUANA COCAINE RX OPIOID PAINKILLERS
HEROIN
is a highly
are are are are
addictive opioid
drug with a high 2X 3X 15X 40 X
risk of overdose
and DEATH
for users. ...more likely to be addicted to heroin.
Adapted from the National Survey on Drug Use and Health, 2011-2013
PRACTICE RECOMMENDATIONS
1. Opioids are inherently dangerous, highly addictive drugs with significant abuse potential, numerous side effects,
lethality in overdose, rapid development of tolerance, and debilitating withdrawal symptoms. They should be
avoided whenever possible and, in most cases, initiated only after other modalities of pain control have been
trialed.
Opioids are among the three broad categories of medications that present abuse potential, the other two being central
nervous system (CNS) depressants and stimulants. Much like heroin, these agents act by attaching to opioid receptors
on nerve cells in the brain, spinal cord, gastrointestinal tract, and other bodily organs. The resultant spike in dopamine
not only reduces the perception of pain, it also can manufacture a powerful sense of well-being and pleasure by
affecting the brain’s limbic reward system.
5When used repeatedly, opioids induce tolerance; greater amounts are required over time as the patient grows
increasingly immune to the drug’s effects.31 This mechanism also contributes to the high risk of overdose following
a period of abstinence.32 Tolerance can be lost in times of sobriety, leading relapsed users to take a previously “safe”
dose with disastrous results.33 The effects of opioids are also mediated by specific subtype opioid receptors (mu, delta,
and kappa) that are activated by endogenous endorphins and enkephalins. The production of endogenous opioids is
inhibited by the repeated administration of outside opioids, which accounts for the discomfort that ensues when the
drugs are discontinued.
Besides the significant abuse potential, rapidly developing tolerance, and agonizing withdrawal symptoms that
accompany opioids, patients also experience serious side effects such as drowsiness, mental confusion, constipation,
and nausea (Table 1).34 These complications, which often necessitate additional medical care, can prevent patients from
performing daily tasks and remaining active in the workforce.
TABLE 1. SIGNS AND SYMPTOMS OF OPIOID INTOXICATION AND WITHDRAWAL
Intoxication Withdrawal
Activation or “rush” (with low dosages) and Depressed mood and anxiety; dysphoria
sedation/apathy (with high dosages)
Euphoria Dysphoria and cravings
Feelings of warmth, facial flushing, or itching Piloerection, lacrimation, or rhinorrhea
Impaired judgment, attention, or memory Frequently, “high” attention
Analgesia Hyperalgesia; joint and muscle pain
Constipation Diarrhea and gastrointestinal cramping, nausea, or vomiting
Pupillary constriction Pupillary dilatation and photophobia
Drowsiness Insomnia
Respiratory depression, areflexia, hypotension, Automatic hyperactivity (eg, hyperreflexia, tachycardia,
tachycardia hypertension, tachypnea, sweating, hyperthermia)
Apnea, sedation, coma Yawning
Adapted from: Martin PR, Hubbard JR. Substance-related disorders. In: Ebert MH, Loosen PT, Nurcombe B. Current diagnosis & treatment in
psychiatry. New York: McGraw Hill; 2000. p. 233-59.
2. Prior to prescribing an opioid, physicians should perform a rapid risk assessment to screen for abuse potential
and medical comorbidities. Alternative methods of pain control should be sought for patients at increased risk for
abuse, addiction, or adverse reactions.
Multiple agencies, including the CDC and Colorado Department of Regulatory Agencies, advocate using an Opioid
Risk Tool to evaluate for factors that might predispose patients to addiction and misuse. While this approach has been
only validated in cases of chronic pain, screening tools may help emergency clinicians identify high-risk patients.35
High-risk criteria include:
• Personal or family history of substance abuse (eg, alcohol, illicit drugs, prescription drugs)
• Age between 16 and 45 years
• Mental health/psychological history (eg, depression, attention deficit disorder, bipolar disorder, schizophrenia)
• History of sexual abuse
In addition, emergency clinicians should consider comorbid health conditions and exercise caution when prescribing
opioids to those at increased risk for adverse drug reactions and accidental overdose.
High-risk comorbidities include:
• Pulmonary comorbidities (eg, chronic obstructive pulmonary disease, sleep apnea)
• Cardiac comorbidities (eg, congestive heart failure)
• Organ dysfunction (eg, renal or hepatic failure)
• Elderly age
63. Emergency physicians should frequently consult Colorado’s Prescription Drug Monitoring Program (PDMP) to
assess for a history of prescription drug abuse, misuse, or diversion.
As of 2014, with the introduction of House Bill 14-1283, all Colorado-licensed prescribing practitioners with Drug
Enforcement Administration (DEA) registrations are required to create an account with the Colorado PDMP.36 Drug
monitoring programs have been shown to influence opioid prescribing practices, especially in the case of lost or long-
term prescriptions.37
These programs can aid providers in identifying patients with multiple recent prescriptions from various providers
(doctor shopping) and help spot those already using other controlled medications on a chronic basis.38 Although there
is limited data to indicate the utility of PDMPs in patient outcomes, they clearly can help inform the conversations
physicians have with their patients.
4. Emergency physician groups should strongly consider tracking, collecting, and sharing individual opioid
prescribing patterns with their clinicians to decrease protocol variabilities.
Prescribing practices vary widely among emergency physicians. Recent data suggests a striking three- to 10-
fold difference in the number of opioid prescriptions written by the lowest and highest prescribing emergency
physicians.39,40 To combat such deviations, we recommend tracking prescribing patterns and providing the comparative
data to those within the practice. This information should not be used punitively, but rather to help clinicians
understand their own treatment habits and facilitate change. Such local sharing has been shown to significantly reduce
the number of opioids prescribed at discharge.41
5. Strongly consider removing prepopulated doses of opioids from order sets in computerized provider order entry
(CPOE) systems.
Computerized provider order entry is an integral part of current emergency department practice. Order sets, which are
part of nearly every electronic medical system, have become a popular mechanism for decreasing clicks, standardizing
care, and meeting clinical metrics. An order for opioids should not be a default. While robust research does not exist,
it is reasonable to assume that the prepopulation of opioid medications on standard order sets increases the number of
these prescriptions written in the ED and may bias treating clinicians. According to the Institute for Safe Medication
Practices, order sets that contain multiple opioids, multiple doses, or multiple routes of administration also appear to
increase the risk of unintentional hospital overdose.
6. Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back
pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments
have failed.
Countless patients present to US emergency departments every year for acute low back pain, many of whom expect
and are prescribed narcotic pain medications.38 However, research shows no significant difference in relief between
nonsteroidal anti-inflammatory medications and opioids.42 Moreover, opioids appear to increase the risk of prolonged
disability at 1 year and decreased function at 6 months.43,44 Alternative treatments, including early mobilization and
physical therapy, can improve return to function and decrease disability and should be used as first-line agents in the
treatment of this complaint.
7. Potential drug interactions must be evaluated, and opioids should be avoided in patients already taking
benzodiazepines, barbiturates, or other narcotics.
The concomitant prescribing of opioids for a patient taking benzodiazepines increases the risk of unintentional
overdose, respiratory depression, and death.45 Patients taking opioids and benzodiazepines together have 10 times the
risk of fatal overdose over those taking opioids alone.46 Patients who are taking multiple opioid prescriptions also are at
a significant risk of overdose.47
78. Patients with chronic pain should receive opioid medications from one practice, preferably their primary care
provider or pain specialist. Opioids should be avoided in the emergency department treatment of most chronic
conditions. Emergency physicians should coordinate care with a patient’s primary care or pain specialist whenever
possible, and previous patient-physician contracts regarding opioid use should be honored.
Clinicians often require patients with chronic pain to sign an opioid contract, which may mandate the use of a single
prescribing provider and pharmacy.48 It is important to honor these control documents, which frequently outline what
the patient can do to manage acute exacerbations of pain and provide guidance for emergency medical providers.
9. Clinicians should abstain from adjusting opioid dosing regimens for chronic conditions and avoid routinely
prescribing opioids for acute exacerbations of chronic noncancer pain.
According to the CDC, it is inappropriate for emergency medicine clinicians to treat chronic pain.45 Long-term
medication regimens should be escalated and managed only by a single provider outside the acute setting. In the rare
instance that a patient’s drug regimen must be adjusted in the emergency department, it should only be done in direct
collaboration with a pain specialist.
Nonopioid treatments can and should be provided for acute exacerbations (see Alternative Pathways section for
recommended modalities). Benzodiazepines and other sedating agents can place the patient at higher risk of overdose
and should be avoided. If the patient is not being seen by a pain specialist, a referral should be initiated.
10. “Long-acting” or “extended-release” opioid products should be avoided for the relief of acute pain.
Long-acting or extended-release opioids are indicated only for chronic pain and should not be used for the
treatment of acute or intermittent symptoms.49 These agents are especially dangerous in opioid-naïve patients, even
at recommended dosages. Long-term opioid use is nearly 4.5 times higher in those started on long-acting opioids
compared to immediate release.9
Short-acting opioids are appropriate for the treatment of acute pain that cannot be managed with other
modalities. They include:50
• Codeine
• Oxycodone — immediate release (eg, Percocet, Percodan)
• Hydrocodone (eg, Vicodin, Lorcet, Lortab, Norco)
• Morphine — immediate release
• Hydromorphone (eg, Dilaudid)
Long-acting and extended-release forms include:
• Oxycodone — sustained release (eg, OxyContin)
• Methadone (eg, Dolophine)
• Morphine — sustained release (eg, MS Contin, Avinza, Kadian)
• Fentanyl — transdermal (eg, Duragesic)
• Oxymorphone — extended release (eg, Opana ER)
Any clinician who prescribes long-acting or extended-release opioids should complete the FDA Risk Evaluation and
Mitigation Strategies (REMS) training program.
811. Patients receiving controlled medication prescriptions should be able to verify their identity.
Patients should be prepared to show identification if opioid pain prescriptions are to be filled. This corroboration
enables a thorough evaluation of the individual’s prescription drug monitoring profile and adds another safeguard
against “doctor shopping.”48
12. Patients who receive opioids should be educated about their side effects and potential for addiction, particularly
when being discharged with an opioid prescription.
Evidence suggests that clinicians do a poor job of educating patients on the risks of opioids (Figure 4). More than 50%
of emergency department patients discharged with opioid prescriptions admit to misusing them in the 30-day period
following their visit.51 In addition, nearly 80% of new heroin users between the ages of 12 and 49 report the previous
nonmedical use of opioids.52
All patients are at risk for opioid misuse and abuse. A prior history of substance abuse, use of psychotropic drugs,
and younger age increase this potential; however, even an opioid-naïve patient with no risk factors can develop
dependence.53,54 When prescribing these agents, it is always appropriate to initiate a detailed discussion about the
significant risk of complications and addiction (Table 2).
FIGURE 4. PUBLIC PERCEPTION OF OPIOID RISK
Only 1 in 5 Americans consider prescription plan medication to be a serious safety threat.
% Major Concern Actual # of Deaths
100% 40,000
35,369
80%
30,000
60%
20,000
39% 16,235
40% 36%
11,208 29%
10,000
20% 20% 19%
586 8
0% 0
Driving Gun violence Severe weather Commercial Prescription pain
or natural airline travel medication
disaster
TABLE 2. THE DANGERS OF OPIOIDS (INFORMATION TO BE SHARED WITH PATIENTS)
Common side effects55 Serious side effects of chronic opioid use
• Nausea/vomiting • Cardiac abnormalities, including prolonged QTc and torsades de pointes56
• Constipation • Sudden cardiac death with the concomitant use of benzodiazepines and
methadone57
• Pruritus
• Hormonal disruptions, including decreased testosterone in males58
• Euphoria
• Decreased luteinizing hormone, follicle-stimulating hormone, and fertility
• Respiratory depression, in women59
particularly with the • Musculoskeletal compromise, including an increased risk of osteoporosis60
simultaneous use of
• Immunosuppression61
alcohol, benzodiazepines,
• Inhibition of cellular immunity via delta and kappa receptors62
antihistamines, muscle
• Hyperalgesia (ie, upregulation of receptors and increased tolerance)63
relaxants, or barbiturates
• Sleep disturbances (eg, shortened deep sleep cycle)64
• Lightheadedness
• Delayed or inhibited gastric emptying, increased sphincter tone, and
• Dry mouth blockade of peristalsis65
913. When considering opioids, clinicians should prescribe the lowest possible effective dose in the shortest
appropriate duration (eg,3. Opioid prepacks should be avoided or eliminated from emergency departments if 24-hour pharmacy support is
available.
Dispensing opioids from the emergency department should be discouraged. Although drug prepacks carry the same
risks as any other prescription, small doses of opioids (IV. Alternatives to Opioids for the Treatment of Pain
“We cannot solve our problems with the same thinking we used when we created them.”
—Albert Einstein
Using nonopioids to address pain management is a novel strategy called Alternatives to Opioids (ALTO). The first
Colorado ALTO program was implemented in 2016 at Swedish Medical Center in Englewood, a busy level-1 trauma
center. The press has inaccurately branded such emergency departments as “opioid-free EDs,” an exclusionary term
that misrepresents the care provided. ALTO simply recommends using opioids infrequently, primarily as second-line
treatments and only after effective nonopioid alternatives have been trialed.
Such programs should be studied by all ED providers and uniformly adopted by hospitals. Through education, the
implementation of novel concepts, and partnerships within the community, an ALTO-based multidisciplinary approach
can transform pain management practice in Colorado.
Treatment Goals
• Utilize nonopioid approaches as the first-line therapy.
• Utilize opioids as a second-line treatment.
• Opioids can be given as rescue medication.
• Discuss realistic pain management goals with patients.
• Discuss addiction potential and side effects with those using opioids.
The ALTO program utilizes the CERTA concept: channels, enzymes, receptors, targeted, analgesia. The CERTA concept
optimizes the following medication classes in place of opioids: Cox-1, 2, 3 inhibitors, NMDA receptor antagonists, sodium
channel blockers, nitrous oxide, inflammatory cytokine inhibitors, and GABA agonists/modulators. Specific agents include
NSAIDs and acetaminophen, ketamine, lidocaine, nitrous oxide, corticosteroids, benzodiazepines, and gabapentin.
The protocol targets multiple pain receptors, making use of nonopioid medications, trigger-point injections, nitrous oxide,
and ultrasound-guided nerve blocks to tailor a patient’s pain management needs and substantially decrease opioid use.
Examples of this approach include:
• Treating renal colic with intravenous lidocaine;
• Managing acute lower back pain with a combination of oral nonopioids and topical pain medications with directed
trigger-point injections;
• Treating extremity fractures with ultrasound-guided nerve blocks; and
• Using an algorithm to manage acute headache/migraine pain with a variety of nonopioid medications.
Only if patients’ pain is not adequately managed using ALTO techniques are opioids used as a rescue medication.
Alternative Medications
Ketamine
Ketamine has been used extensively in the emergency department for procedural sedation and rapid-sequence intubation.
Recent research has demonstrated that a low (subdissociative) dose (0.1-0.3 mg/kg IV) is safe and effective for pain
management.78-81 Due to the relatively short-lived analgesic effects of the drug, the initial bolus can be followed by an
infusion (9-30 mg/hour) for sustained effect.92-95 Caution should be used in any patient with a significant psychiatric
history, and use should be avoided in anyonet with a history of post-traumatic stress disorder.
12Lidocaine Lidocaine is an ideal agent for treating visceral and central pain, and also may be useful when narcotics are inefficient or lead to undesirable side effects. Intravenous or topical (4% or 5% transdermal patch) doses are effective for controlling renal colic and neuropathic pain associated with conditions such as diabetic neuropathy, postoperative or post-herpetic pain, headaches, and neurological malignancies.82-83 Topical lidocaine also is an appropriate treatment for low-back pain.84-88 Intravenous lidocaine should be used with caution in any patient with a significant cardiac history. Side effects of the drug are minimal when used sparingly. Trigger-Point Injections A focal area of spasm and inflammation (eg, trapezius, rhomboid, low back) can be associated with chronic myofascial pain syndrome. Palpation of the trigger point should fully reproduce pain, which may be referred to other areas (eg, nodule or taut band of spasm). Dry needling will cause a disruption of the spastic feedback loop by interrupting abnormal activity in the sensory and motor nerve endings and muscle fibers. Using local anesthetics such as marcaine or lidocaine for this procedure often resolves pain and decreases soreness. Indications for this approach include a palpable, taut band or nodule, reproducible pain with palpitation, or a chronic painful condition.89-92 Trigger-point injection has also been found to be a successful treatment strategy for migraines.93-95 Nitrous Oxide Nitrous oxide is a tasteless, colorless gas administered in combination with oxygen via mask or nasal hood at a maximum concentration of 70%. The gas is absorbed via pulmonary vasculature and does not combine with hemoglobin or other body tissues. Featuring a rapid onset and elimination (
Special Populations
Not all patients are appropriate candidates for each agent suggested in the ALTO treatment protocol. All medications
should be administered with thoughtful consideration of patient-specific factors such as age, organ function, comorbidities,
and other medications being taken.
Geriatric Patients
Great care should be taken when treating elderly patients. Some of the therapies suggested may be inappropriate for use
in this vulnerable population, including dicyclomine, haloperidol, diphenhydramine, and muscle relaxants. The Beers
Criteria list is a well-established resource that should be consulted when making treatment decisions for patients older
than 65 years.109 When possible, consider prescribing topical agents instead of oral or intravenous drugs. Also consider
recommending heat, massage, and physical therapy on discharge for musculoskeletal pain.
Renal Dysfunction
Not all ALTO agents are safe for patients with renal dysfunction, particularly NSAIDs. In patients who cannot receive
systemic NSAIDs, consider prescribing topical agents such as diclofenac gel or patches.
Heart Failure
Not all ALTO agents are recommended for use in patients with heart failure, particularly steroids and NSAIDs. For patients
in whom these medications should be avoided, consider prescribing topical alternatives.
Pregnant Patients
Pregnant women should be excluded from the ALTO protocol. Many of these agents are contraindicated in pregnancy,
including haloperidol, NSAIDs, and valproic acid.
Pediatric Patients
Do not use the ALTO protocol when managing children younger than 15 years or less than 40 kg. Although ALTO principles
are applicable to the pediatric population, precautions should be considered and agents must be dosed appropriately.
PRACTICE RECOMMENDATIONS
Note: Many of the recommendations in the following section are based on the ALTO clinical model. A full discussion of
each drug and procedure is beyond the scope of these guidelines. Appropriate references are listed, however. (See Figure 5
for specific treatment pathways by indication.)
1. All emergency departments should implement ALTO programs and provide opioid-free pain treatment pathways
for the following conditions (see Appendix 1):
a. Acute on chronic opioid-tolerant radicular lower back pain
b. Opioid-naive musculoskeletal pain
c. Migraine or recurrent primary headache
d. Extremity fracture or joint dislocation
e. Gastroparesis-associated or chronic functional abdominal pain
f. Renal colic
2. Emergency departments should integrate ALTO into their computerized physician order entry systems to facilitate a
seamless adoption by clinicians.
3. For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids,
topical medications, trigger-point injections, and (for severe pain) ketamine.
4. For headache and migraine, consider a multimodal treatment approach that includes the administration of
antiemetic agents, NSAIDs, steroids, valproic acid, magnesium, and triptans. Strongly consider cervical trigger-
point injection.
145. For pain with a neuropathic component, consider gabapentin.
6. For pain with a tension component, consider a muscle relaxant.
7. For pain caused by renal colic, consider an NSAID, lidocaine infusion, and desmopressin nasal spray.
8. For chronic abdominal pain, consider low doses of haloperidol, diphenhydramine, and lidocaine infusion.
9. For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while
setting up for ultrasound-guided regional anesthesia.
10. For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection.
11. Outpatient prescribing patterns should follow ALTO principles by minimizing opioids and utilizing a multimodal
approach to adequately control pain. (See Appendix 2 for discharge prescribing guidelines.)
FIGURE 5. PAIN PATHWAYS BY INDICATION
15POLICY RECOMMENDATIONS
1. Hospitals should update institutional guidelines and put policies in place that enable clinicians to order and
nurses to administer dose-dependent ketamine and IV lidocaine in non-ICU areas. (For more information,
download the Denver Health policy on Ketamine for Acute Pain in the ED.)
2. Emergency departments are encouraged to assemble an interdisciplinary pain management team that includes
clinicians, nurses, pharmacists, physical therapists, social workers, and case managers.
3. Reimbursement should be available for any service directly correlated to pain management, the reduction of
opioid use, and treatment of drug-addicted patients.
Marijuana Use in Chronic Pain
Patients frequently inquire about the use of medical marijuana for the treatment of painful conditions.
Although a number of studies have been conducted on the drug’s potential role in the treatment
of chronic pain, results are limited. Most of the trials have been short, and many have focused on
neuropathic pain resulting from a narrow range of etiologies; fewer than 3,000 patients have been studied.
Marijuana plants are comprised of more than 65 cannabinoids, including tetrahydrocannabinols (THC)
and cannabidiols (CBD). It is important to note that while studies have shown the effectiveness of treating
pain with a combination of these two chemicals, more research is needed to identify the positive and
negative attributes of the remaining active ingredients.110-112
The current scheduling nature of the drug presents several roadblocks for researchers.113,114 While
previous studies have focused on the use of medical marijuana for alleviating chronic pain, there are
interesting links between recently enacted state laws and an overall decline in opioid-linked overdoses
and deaths. According to a study that examined medical marijuana laws and opioid analgesic overdose
rates from 1999 to 2010, “States with medical cannabis laws had a 24.8% lower mean annual opioid
overdose mortality rate compared with states without medical cannabis laws.”115
At this time COACEP takes no position on the use of medical marijuana for the control of chronic
pain, and recommends that emergency physicians refrain from prescribing or advocating its use until
definitive studies have been conducted.
16V. Harm Reduction in the Emergency Department
“Patients come to us for care, not for judgment.”
—Greg L. Henry, MD
Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.
The approach is predicated on respecting patients and their choices, removing stigma, and meeting them “where they are” and
not where we believe they should be. In a perfect world, patients would be compelled to quit by logical physician counseling.
In reality, however, patients must possess the internal resolve to pursue sobriety before they can enter into recovery; even the
most well-meaning advice can be counterproductive if it is disconjugate with the situation. The simplistic directive to “stop
using because you may die” is ineffective and often deleterious to the physician-patient relationship.
Harm reduction aims to prevent the spread of infection, including HIV/AIDS, hepatitis B and C, sepsis, and endocarditis;
reduce the risk of overdose and other drug-related fatalities; and decrease the negative effects drug use may have on
individuals and communities.
Of the thousands of patients who present with opioid-related emergencies, ranging from withdrawal to constipation to
overdose to injection-related infections, the fact is that most are not ready to quit on the day they visit the ED. Given the
unprecedented scope and destruction of this epidemic, clinicians can and must do better in counseling and treating the
addicted patient who is not ready to stop using.
Initially developed in response to the US AIDS epidemic, the harm reduction philosophy primarily has been used in
recent years for the treatment of people who inject drugs (PWID); however, its principles are broadly applicable to most
substance-abusing patients. Injection drug use is intertwined with the growing opioid epidemic; roughly 75% of injection
heroin addictions originate with prescription opioids.30 Significant risks are associated with this behavior, as injection drug
use accounts for between 12% and 26% of new HIV diagnoses and the majority of new hepatitis C infections.116,117
Health care providers have been shown to have a negative view of patients with substance abuse problems, a dynamic that
erodes both clinician empathy and patient care.118 A quote from the National Harm Reduction Coalition patient manual
captures the stigma these patients feel when receiving treatment in the emergency department:
“Only use the emergency room as a last resource for getting your abscess drained. Chances are the doctor you see will not be
too sympathetic to your plight, under-medicate you for pain, make a large incision, and provide no follow-up or aftercare.”
As a result, patients who abuse opioids and injection drugs often go to great lengths to avoid medical care or sign out
before treatment is complete. It is imperative that we begin to change these perceptions by making the ED a welcoming
place for those who seek care (Table 3). Drug addiction truly is a physiological disease, defined by genetic predisposition
and long-term changes in brain structure and function. Clinically, patients often suffer from uncontrollable, compulsive
drug cravings that render them powerless even in the face of catastrophic social and health-related consequences.119
TABLE 3. PITFALLS IN THE TREATMENT OF PWIDS
• It is not uncommon for clinicians to assume that drug users don’t care about their health; such misperceptions
are noticed by patients. Fearing this negativity and condescension, many drug users avoid the emergency
department by trying to “doctor” themselves.
• Some providers automatically undertreat or minimize pain when they suspect drug-seeking behavior, or perform
procedures (eg, abscess drainage) with inadequate anesthesia in order to “teach the patient a lesson.”
• Health care providers occasionally bring in other colleagues to gawk at patients without their permission.
However, these insensitive “Look at the crazy thing this junkie did to herself/himself!” conversations are
inappropriate.
• Nurses and doctors should not contact law enforcement without the patient’s knowledge.
• Vague or unrealistic aftercare plans are futile.
• Long speeches and shaming life lectures about drug use can and should be replaced by educational information
about risk reduction.
• Patients often overhear health care providers talking about them negatively outside of the room or behind
a curtain. Assuming the patient can’t hear them, clinicians can be heard warning other providers about the
“druggie” or “drug seeker.”
17Harm reduction and therapeutic relationship-building is especially pertinent in Colorado, where buprenorphine and
methadone treatment programs are scarce and plagued by long waiting lists. This inaccessibility means that most opioid
users will continue to abuse these medications, many within hours of discharge. There is one great barrier that remains to
be addressed, namely the fact that most emergency providers are unfamiliar with harm reduction principles, unaware of
how to perform effective interventions, and lacking the education and resources needed to integrate harm reduction into
their practices.
PRACTICE RECOMMENDATIONS
1. Patients who abuse opioids should be managed without judgment; addiction is a medical condition and not a
moral failing. Caregivers should endeavor to meet patients “where they are,” infusing empathy and understanding
into the patient/medical provider relationship.
It is imperative that we work to better understand addiction and end the stigma associated with prescription opioid
abuse. A harm reduction mentality, as outlined below, offers a pragmatic approach to mitigating the associated risks
without casting blame or alienating those who seek help.
Allow patients to seek treatment—or not—at their own pace (Table 4). Pressuring or forcing patients into treatment for
substance abuse is fruitless, violates the autonomy, and creates an adversarial rather than therapeutic relationship.
TABLE 4. COUNSELING PATIENTS WITH ADDICTION
DO DON’T
• Use neutral language when referring to drug use. • Use negative terminology such as
• Assess the patient’s readiness to change. “addict” or “junkie.”
• Respect the patient’s decisions regarding treatment. • Tell the patient they are ruining their life
• Encourage patients to be honest with providers about any drug use. or are going to die.
• Make information available that is specific to the needs of the • Attempt to pressure the patient to begin
patient. substance abuse treatment.
• Remember harm reduction principles: • Make assumptions about the mental or
physical health of patients with opioid
— Accept and don’t condemn patients who use drugs.
use disorders.
— Offer resources without pressure or judgment.
• Let the stigma associated with injection
— Improve quality of life for patients with opioid use disorders. drug use affect how a patient is treated.
— See the individual as a person, rather than their addiction.
2. Every emergency clinician should be well-versed in the safe injection of heroin and other intravenous drugs, and
understand the practical steps for minimizing the dangers of overdose, infection, and other complications. When
treating patients with complications of IV drug use, injection habits should be discussed and instruction should
be given about safe practices.
Heroin offers a cheaper high for patients addicted to prescription opioids, a factor that has contributed to the
drug’s increasing popularity and contributed to a rise in communicable (eg, HIV and hepatitis C and B) and
noncommunicable diseases (eg, abscesses, cellulitis, and endocarditis). Data collected by Denver’s Harm Reduction
Action Center estimates that 24% of PWID are hepatitis C-positive; injection drug use is the leading transmission
method of this pathogen in the US. A notorious HIV outbreak in one tiny, rural Indiana town is a cautionary tale about
what can happen when safe injection practices are ignored. The tightknit community of Austin (population 4,000) was
ravaged by the virus in 2015 when 190 new cases were diagnosed — all of which could be attributed to a local epidemic
of injection oxymorphone abuse.
The vast majority of medical providers are unfamiliar with drug injection methods and are unprepared to discuss
safeguards with their patients. Most IV drug users learn from their peers, from whom they can inherit dangerous
habits. Counseling about safer injection practices should be offered prior to discharging any IV drug user (Figure 6).
The following guidelines can be shared to help reduce the substantial risk of infection and overdose.
18Avoid using alone. Drug users should inject in the presence of others for safety. Colorado’s Good Samaritan Law
protects individuals who call 911 to report an overdose, exempting them and the patient from arrest and prosecution
for small drug charges.
Always carry naloxone. The evidence in support of naloxone is staggering. Since 1996 the opioid reversal agent
has saved more than 26,000 lives.120 Because most overdoses are witnessed and transpire over hours, naloxone is
our patients’ most powerful tool for preventing overdose death. The antidote should be dispensed in the emergency
department to anyone suspected of abusing IV drugs, and at-risk patients should be encouraged to keep the naloxone
within reach at all times.
Try tester shots. Variations in drug potency are common, especially with the popular practice of cutting or
substituting heroin for fentanyl or carfentanyl. When trying a new product, patients should use a small test dose (ie,
tester shot) to gauge its potency.
Avoid sharing equipment. Although HIV can survive only minutes outside the body, it can live for days to weeks
inside hollow-bore needles. The risk of transmission is highest when drug paraphernalia is shared between multiple
users within a short period of time. Hepatitis B and C are particularly virulent, and can survive between 1 and 3 weeks
outside of the body. These pathogens can be spread easily via injection equipment (eg, needles, syringes, cookers
(spoons), injection water, and cottons) (Figure 7).
Practice good hygiene. Always encourage hand washing and cleansing of the injection site. If no running water is
available, benzalkonium chloride towelettes can be a good substitute. Recommend the use of alcohol pads to sterilize
skin prior to injection.
Use sterile equipment. Communicable disease can be avoided by not sharing needles. Reusing equipment increases
the risk of bacterial contamination. Patients can obtain new equipment for free through local syringe access programs
(formerly referred to as needle exchange programs). If such resources are unavailable, advise patients to purchase
needles, syringes, and alcohol pads at pharmacies. If new paraphernalia cannot be obtained, patients should clean their
existing equipment with bleach for at least 2 minutes, flushing all components, and rinsing with clean cold water. The
average injection drug user injects 3 to 5 times per day.
Use sterile water to prepare the product. Many infections stem from unsafe water supplies; some users report
using river water, toilet water, or saliva to dissolve product into an injectable form. Bottled water is NOT sterile!
Optimally, patients will have access to single-use containers of sterile water. If these are unavailable, water should be
sterilized by heating it at rolling boil for 10 minutes.
Protect veins. Patients should be advised to use highest gauge (smallest) needle possible; rotate injection sites,
starting distally; drink water to remain well hydrated; use citric acid if an acidic solution is required to dissolve product
(never lime, lemon, or orange juice, which are more sclerotic and carry a higher risk of infection). Advise against using
the jugular, femoral, or pedal veins, which can further increase the danger of infection.
19FIGURE 6. EDUCATING IV DRUG USERS
Safer Injecting (For Patients)
AVOID THE HEAD AND NECK
Overdosing is more likely when you
shoot up near areas closest to the
heart and brain. Abscesses are more
dangerous here, too.
ARMS
Use surface veins in arms
if they are in good shape.
Rotate sites regularly.
AVOID THE
WRISTS
Nerves, veins, HANDS
and arteries are AND FEET
close together The veins on
in the wrists. the back of
Injecting here is the hands and
dangerous! top of the feet
are sensitive.
Injecting here
AVOID THE will hurt! Inject
GROIN AREA slowly.
There are major
arteries here —
if you hit one, LEGS
you could lose Blood flows slowly
a leg or die. in the legs, so
Never inject inject slowly. Be
into or around careful to avoid
the genitals. the artery behind
the knee, which
is prone to blood
clots.
20FIGURE 7. COMMON SUPPLIES DISPENSED THROUGH SYRINGE ACCESS PROGRAMS
Sharps
container
Cooker with handle
Tourniquet
3 capped
needles and
syringes Syringe
and
uncapped
needle
Sterile
water Cottons
Alcohol Antibiotic Adhesive bandage
prep pad ointment
3. Emergency department patients who inject drugs should be referred to local syringe access programs, where they
can obtain sterile injection materials and support services such as counseling, HIV/hepatitis testing, and referrals.
Patients engaged in such behavior should be counseled on the risks of bloodborne pathogens, particularly HIV and
hepatitis, which can be transmitted via shared needles and drug preparation equipment. Syringe access programs
have demonstrated cost-effectiveness in reducing HIV transmission and prevalence.121 The additional resources these
centers often provide (eg, sterile water, cooking units, and cleaning solutions) also can help reduce such dangers.
The World Health Organization (WHO) suggests a “compelling case that needle and syringe programs substantially
and cost effectively reduce the spread of HIV among IV drug users and do so without evidence of exacerbating
injecting drug use at either the individual or societal level.”122 In 2000 the American Medical Association (AMA)
adopted a position strongly supporting the efficacy of these programs when combined with addiction counseling.123
A complete list of local syringe access/harm reduction programs can be found through the North American Syringe
Exchange Network (Figure 8).
21FIGURE 8. LOCATIONS OF COLORADO SYRINGE ACCESS PROGRAMS
1. The Works 5. Northern Colorado AIDS Project
3450 Broadway 400 Remington, Suite 100
Boulder, CO 80304 Ft Collins, CO 80524
(303) 413-7533 (970) 484-4469
2. Access Point Pueblo 6. Rocky Mountain Morpheus Project
Available Fridays Only 414 Taos Street, #B
505 West 8th Street Georgetown, CO 80444
Pueblo, CO 81003 720-401-6569
(719) 621-1105 (Syringe services not currently offered at this site.)
3. Denver Colorado AIDS Project 7. West Colorado Aids Project
2480 W 26th Avenue, Suite B-26 805 Main Street
Denver, CO 80211 Grand Junction, CO 81501
(303) 837-0166 (970) 243-2437
4. Harm Reduction Action Center 8. Aurora Syringe Access Services
231 E. Colfax Avenue 1475 Lima Street
Denver, CO 80203 Aurora, CO 80010
(303) 572-7800 (Only available Wednesdays 1–3:30 pm.)
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